EPA Form 8570-4 (Rev. 8-94) Reverse *U.S. GOP: 2000-519-239/94558

Instructions and Paperwork Act Notice

Please Read Carefully Before Completing This Form

Paperwork Reduction Act Notice

The public reporting burden for this collection of

information is estimated to average 1.0 hour per

response, including familiarization with the form,

organizing the necessary information, and

completing the form. Send any comments

regarding the burden estimate or any other aspect

of this collection of information, including

suggestions for reducing this burden to: Chief,

Information Policy Branch, 2136, U.S.

Environmental Protection Agency, 401 M Street,

S.W., Washington, D.C. 20460.

Instructions

The complete chemical composition of each pesticide must be known so it can

he evaluated for registration under the Federal Insecticide, Fungicide, and

Rodenticide Act, as amended.

This form is designed for reporting the ingredients used in the formulation of

a pesticide product. It must be completed and submitted with each application

for new registration of a pesticide and application for amended registration if

the revision involves a formula change.

Block A: Check the appropriate action for which you are submitting the

form.

Block B: Number all pages consecutively. Enter on each page the total

number of pages submitted. If more than one page is required, number them

"1 of 2", "2 of2", "3 of 3", etc.

1. Name and Address of Applicant/Registrant: Enter the name and

address of your firm or authorized agent.

2. Name and Address of Producer: Specify the name of the producer and

the address of the site where this product will be produced.

3. Product Name: Specify the complete name of this pesticide product as it

will appear on the label. This name must be the same as that which appears

on the application form.

4. Rcgistlation Number/Filc Symbol: Enter the EPA registration number

or file symbol, if known for this product

5. EPA Product Manager/Team Number: Enter the name and team

number of the EPA Product Manager assigned to this product, if known.

6. Country Where Formulated: Specify the country where this product is

formulated

7. Weight per Gallon/Bulk Density: For a liquid product specify pounds per

gallon of formulated product. For a powder or granular product, enter the

hulk density of formulated product (as used). Enter weight per unit if the

product is produced as a tablet, briquette, or other uniformly shaped product

8. pH: Enter the pH of aqueous formulations and products which are either

dispersible or soluble in water. If not applicable enter "N/A".

9. Flash Point/Flame Extension: Specify the flash point as determined by

the regulations for pressurized products and/or products known or suspected

to burn. State the results of the flame extension test for pressurized products

including positive flashbacks.

10. Components in Formulation: List as actually introduced into the

formulation. For each component in your formulation, provide the product

name, commonly accepted chemical, the trade name, and the Chemical

Abstract (CAS) number for each identifiable ingredient present in the product.

CAS numbers may be obtained from the Chemical Abstract Service of the

American Chemical Society, Columbus, OH. For each original and

alternate source of each active ingredient in the product, indicate the percent

purity of the manufacturing use product, technical product, or other source

of active ingredient. If one or more components will be obtained from more

than one source, enter all alternate sources and all alternate EPA Reg. Nos.

in blocks 10, 11, and 12 or on a separate attachment.

Attention: (Special Instructions for Columns 10, 13, and 14) Any impurities

greater than or equal to 0.1% (or less than 0.1% if the impurity is

toxicologically significant) which are associated with the active ingredient(s)

of n technical grade (manufacturing or reformulating use) product or an end

use product produced by an integrated formulations system should also be

listed in column 10, and the corresponding amount, percent by weight, and

upper certified limits in columns I3 and 14.

11. Supplier Name and Address: Provide the name and address of the

supplier of each component in the formulation. If one or more components

will be obtained from more than one source, specify the names addresses

of the alternate sources also.

12. EPA Reg. No.: Specify the EPA registration number, if any, for each

active ingredient in the formulation. If an unregistered active ingredient is

used, have the suppliers submit the chemical specifications, as well as any

data required under 40 CFR Part 158.

13. Each Component in Formulation a. Amount: Specify the quantity of

each component as actually introduced into the formulation. Units (e.g.,

pounds, grams, gallons, liters) should be expressed as used in the

formulation. If the quantity is a liquid measure, enter the volume and the

specific gravity or the pounds per gallon of the

component.

b. Percent by Weight: Specify the weight percentage of each component in

your formulation. Check Your Calculations. Note that the weight percentage

in many cases will not agree with that shown on the label ingredient statement

where the weight percentage of the per active ingredient(s) must he declared.

Attention: Producers of Microbial Products: Special Instructions for

Column 13b.) Please state the percent of active ingredient in British

International Units (BIUs). International Toxic Units (ITUs). Polyhedral

Inclusion Bodies (PIBs)(viruses), Colony Forming Units (CFUs)(Fungi), as

appropriate, and include an equivalent statement of active ingredient per

milligram, ounce, pound, etc. of product (e.g., a 50% active Bacillus

thuringiensis product may have an equivalency value of 1.59 million

Aedis aegypti ITU per pound of product.

14. Certified Limits: These limits are to be set based on representative

sampling and chemicnl analysis (i.e., quality control) of the product.

a. Upper Limit: Specify the maximum percentage of each active ingredient,

intentionally added inert ingredient, and any impurities greater than 0.1% to

he permitted in the product.

b. Lower Limit: Specify the minimum percentage of each active ingredient

and intentionally added inert ingredient to he permitted in the product.

15. Purpose In Formulation: Specify the purpose of each ingredient both

active and inert. (For example, disinfectant, herbicide, synergist surfactant,

defoamer, sequestrant, etc.) If space is insufficient, abbreviate.

16. Typed Name of Approving Offirial: Complete this item for

identification of individual to he contacted if necessary

17. Total Weight: Specify the total weight of the batch (column 13a.)

18-21: Complete these items for identification of individual to be contacted if

necessary.